A revamp of medical curriculum

Literature and philosophy must be included to ensure overall development

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Supported by an Unrestricted
Educational Grant from

Dr. Sundeep Mishra

Professor of Cardiology, Editor-Indian Heart Journal

AIIMS, New Delhi

Discussing shortcomings of the standard medical curriculum, Dr. Sundeep Mishra says,
“Our medical curriculum trains doctors to disconnect with emotions. But if you ignore
emotions, you ignore the human being component and treat a patient like a machine.”
“The focus of medicine must shift from preventing death to a more holistic approach, in
which, you give the patient support and emotional comfort, so that he is in a better
position to deal with the pain or even death, as in case of terminally-ill cancer patients.”
“Paradoxically, Suicide rates are the highest in the medical profession,” he points out
and says, “Studying or working for 14-15 hours a day over 10-15 years to build a
medical profession isolates the student from his family and disconnects him from the
society.”
“Some literature and philosophy must be included to ensure overall development in
sync with the society,” he adds.
Dr. Mishra talks about ‘A Clockwork Orange’, a movie in which a criminal becomes more
receptive to the violence in the society and transforms as a result of watching grotesque
images and graphics.
“Similar movies must be shown to medical students to sensitize them. The more they
understand the pain and suffering of a patient, the better care they can provide.”
“Doctors cannot give you immortality, they can only take care of discomfort and prolong
life to some extent,” Dr. Sundeep highlights increasing cases of doctors being beaten up
by relatives of lost patients.
Attributing this violence to the changing doctor-patient relationship, Dr. Sundeep
Mishra says, “Initially, the doctor-patient relation was like that of a parent and a child. A
Child knows that a parent’s decision would be for the best. But now, this relation has
turned into a client-vendor like contract.”
“In this era of communication, doctors need to effectively communicate risks of side
effects and mishaps. Since patients like to be informed, they can be given literature to
read, so that they themselves reach the same conclusion as the doctor suggested.”
Even if a doctor has been negligent, Dr. Sundeep says, “People must approach the court
of law instead of taking authority in their hands.”

</b> The subject is slightly different on what we discuss routinely, but it is a very important topic and it is the need of the hour.
In the medical curriculum both MBBS as well as post graduation, it has been found that the focus is entirely on the algorithm based
approached diagnosis and treatment of the patient. Often in this approach, the patient angle or the patient’s emotional angle gets
neglected and that results in lot of frustration and end result is that even when the right therapy is there and right diagnosis is
there the patient’s are not satisfied and they leave the hospital and Doctor with a grudge. Sir, I would like to have your opinion
on this subject.

Dr. Sudeep Mishra

</b> I think you are exactly right, the classical approach for medical profession has been that you have to treat the patient who
is on board and disconnect with emotions. So you kind of treat the patient like a machine and if that machine has got wrong you fix that
machine. So that process starts right from the day one. When you enter your anatomy lab you see a cadaver lying there and what you are
expected to do is to go and cut that and dissect it and to find out the disease or whatever anatomical correlations between different things.
Completely ignoring that now this was a form of human being actually who is lying there and all the emotional aspects are actually taken
away, you do not treat it like a human being who has been unfortunate to lie there, but treat it like a machine and kind of cut it apart and
find out what is what. So, I think that particular training goes right on till the end of the training where the prospective doctor is
trained to keep the emotions away and treat every disease like a machine process which has gone wrong and like a machine which requires
fixing and fix it like that. So you might heard people saying that okay this is my father how can I treat him, so we find another physician
to come and treat my father. Because I can not treat my father, because then emotions will come in, but I think that particular approach is
completely flawed in current circumstance, because what happens is that emotions are integral part of the disease process not only disease
process are the integral part of the human being that we are treating. We are not treating particular defect, we are treating the whole
human being and if you ignore the emotions then you ignore the human being human component and you try to treat him like a mechanical
problem.So that is why this whole things comes up and that is why you know what happens now we see that there is a disconnect between
the doctor and the patient so that disconnect happens a classic example is say terminally ill cancer patient.You know the main reason for
medicine as many people will tell you is to prevent death, but in a terminal ill cancer patient you can not prevent death that is inevitable.
In any case, every human being who has come here has to die. So if you focus as medical professions, first job to prevent death then it has
already failed, because everybody who has come in will going to die some point of time, so that means that medicine has already failed,
because although you can prolong life, but you can not prevent death. So that is why I think the focus of medicine should shift from
preventing death to holistic approach to the whole patient were all these concerns are addressed in a terminally ill cancer patient you
can not prevent death, but you can give him support, you can give him emotional comfort to bear the death to bear the pain that
accompanies that particular thing and I think at that point of time that is the most important thing to do. So I feel that medical
curriculum should be completely revised. Another problem of medical curriculum is that they take the course of science, which is
completely away and that make the person who is engaged in that particular process, because the training is very long and it might take
10-15 years to train properly into the medical profession and by that time, the doctor gets disconnected from society, because he is
focussed into only himself and the patient’s sometimes he may ignore his family because 14 -15 hours, he has to spend with his job, with
learning, education etc, so he even ignores the family and therefore you see that the suicide rates are highest in the medical profession
among all other profession suicide rates are highest in the medical profession, because it completely disconnects. Man is a social
animal and if you give away the society you become disconnected from the society very high chance of suicide rates so paradoxically
doctors have the highest suicide rates and that is the exact reason because they disconnect so I think you know not only medical thing
should be included in curriculum but some literature some philosophy should included as a part of their curriculum so that you know
they have a overall development in the society rather than act as an observer outside the society looking at the patient’s.

Dr. Manish Verma

</b> Any suggestions or any ideas you will give, you have already said that philosophical should be one of the subject, but to make it
more practical any suggestions you can give?

Dr. Sudeep Mishra

</b> I think simple suggestions are that you know in the curriculum itself there should be care scenarios with emotional
attachments and you can show them those particular case scenarios, where terminally ill cancer patients there can be sensitization towards
death there they visit the wards were people are dying actually and then they will not ignore death. People kind of postpone this death
and they just like at life, but death is also a part of the thing so have training there another very actually very interesting experiment,
there was a movie I don’t know whether any of you have seen that particular movie which was ‘A Clockwork Orange’ where there was a kind
of criminal person with a criminal bent of mind so what they did was they sensitized him to all the violence in the society. So in that movie
what they did was he was shown these images graphic movies where his mind was changed as a result of these images and he became
more receptive to the society so that experiment was carried out. Similarly, I think you know some of these tragic movies may be shown
to doctors where they can appreciate the pain of people who are involved there and that can help them. So these are some of the
practical examples also philosophy should be part of the curriculum they should have one course in philosophy one course in arts,
because arts does two things, it shows you the similarities and also the dissimilarities so that doctor also can basically associate
with the patient and also disassociate both these values will come out so arts philosophy they should be regular part of curriculum.

Dr. Manish Verma

</b> how far the doctors also see patients as one individual they forget that every patient has a family and their relatives are there
and once he goes back there will be a family life there will be a society in which the person is going to leave. The focus is entirely on the
disease management so any ideas on that that how the instead of patient keeping as one individual the entire family in which the patient lives
can be taken together.

Dr. Sudeep Mishra

</b> So when patient is visited there should be family member their anything that is discussed should be done in context with the
whole social situation and I think all these things are part of it and that particular training should start right from the beginning.

Dr. Manish Verma

</b> Another different topic although somewhat related is in India, we have been seeing increasing violence against doctors and this
has happened more commonly now a days and this is actually resulting in lot of frustration and kind of a separation. It is increasing the gap
between the doctor and the patient. Doctors are becoming more and more careful they are ordering for more investigation, they are trying to
be more cautious in discussing with the patient’s about their prognosis and treatments and so on. In a way, it is affecting the way that
patients are getting managed. Sir any of your opinion or any ideas on that.

Dr. Sudeep Mishra

</b> I think you are exactly right. I think violence against doctors and other health care workers is now taking an epidemic
proportion.There does not go a single day where you do not see a report, where we have recently heat that one dengue patient died and the
relatives got together and beat up the doctors and also the staff.. You know dengue is sometimes can be life threatening likewise if cancer
patient dies how is doctor is responsible, doctor can not give you immortality, they can only take care, prolong life may be take care of some
discomfort that’s all a medical personnel can do.They can not prevent somebody from dying more or less, I mean negligence apart.This is the
usual story.So how do you make doctor or any hospital or any body else responsible for an unfortunate circumstance that any way happens.
If somebody dies of road traffic accident you know you can not hang the prime minister of the country because somebody died. So I think
these are some grossly over reaction in many case, but let us go philosophically into why that happens what has happened over a period of
time. Initially, between the patient and doctor relationship has changed. Initially, it was a parent-child relationship. So patient was a
child and doctor was the parent and as we know that parent knows what is the best for the child and child accepts whatever the parent tells
and he acts on his behalf and there is no kind of big discussion or argument between the parent and the child on any aspect including even
sometimes later on in marriage and in jobs etc. Initially that kind of relationship was present. Now that relationship has changed. It has
kind of became a client and deliver or a vendor kind of relationship, so I think that change in relationship is the reason for all these problems.
Now you would ask me why this relationship has changed. So fifty years back dominant population was divided into two classes, either they
were elite which were of course a minority 5% or so 95% were working class. So working class basically the whole philosophy is discipline
following the rules and you will see that these working class are always in the uniform and things like that so basically for them discipline
is the most important thing they will never go against the rules but what has happened is suddenly the another class has come in between,
which is the intellectual class. Now intellectual class is defined by challenging the authority by asking questions by questioning everything
as a matter of fact and if satisfactory answers are not given for these questions, so if the parent does not satisfactorily answered the child
then child gets violent. Same kind of thing is happening. You know the patients have certain questions they have certain dilemmas. They
have lot of things and doctors somehow does not have either time or does not want to answer these questions, does address these question
then there is a disconnect and then naturally no other option but to resort to violence some times. So as you said how to address these
problems. Now the time has come where you need to carefully discuss everything with your patient give him/her the right perspective. Give
them lot of literature to read and so that they themselves come to the same conclusion as the doctor has already released that okay this is
the best course of my treatment and these are the issues, these are the mishaps that can happen. What commonly happens is in our context
for eg if somebody comes for angiography, you ask him okay we will do an angiography we will find out what the diseases is? But the doctor
did not tell you that angiography can be risky sometimes very ocassionally, people can even die out of it. Now if this person has come
walking got an angiography done and statistically some people die out of angiography and if he unfortunately, one of them and he dies then
very likely the relatives may behave violently against the doctor. Because now he understand that the gap has been at the level of
communication. So I think this is the era of communication and doctors need to effectively and accurately communicate the problems with the
patient and if they are unable to do so for any reason whether they themselves lack that information or whether they do not have time or
whether they have that still parental-child kind of attitude, if any of these things are there then there is a high probability that violence
will happen So people how come for dengue they have to be clearly told that some of them can die, we will try our best to save it this the
problem of your patient he is higher risk for dying we will still try but we can not promise and then if dies then you can say that we tried.,
but if you say dengue nothing no problem we will give some fluids that and also don’t address their concerns properly so they come out with
some symptoms, no doctor he is gasping something and you say okay we will see him. We will come and then if you dismiss those things then
that is the point where this disconnect will happen, but of course there is a societal aspect society also needs to understand that you have
to follow the rules even if the doctor is negligent there are some other authority who will address this problem you are not the one to
address that problem. You can take him to court, they can decide the kind of compensation they can even put him in jail if the gross
negligence is found but the patients are nobody to react against this because the law and force of authority they should be informed so if
that particular part clear from both sides I think these problems will resolve.

Dr. Manish Verma

</b> Thank you so much sir very nicely you have summarized both the sides, doctor needs to be more careful in addressing the prognosis
and also needs to be talking to the patients and their relatives about what is going to be the end result of the treatment which he is going
to not promising falsely that everybody can get cured and similarly on the patient side we understand that there is an emotional angle when
the relative is dying but violence cannot be justified in any situation. There are authorities whom they should talk and they should discuss.
Thank you so much sir.